On Not Being Enough and the Therapist's Ego Ideal

I would like to begin with a quote from Harold Searles's (1967) classic paper “The ‘Dedicated Physician’ in Psychotherapy and Psychoanalysis.” Searles opens the paper with “Patients cause one to doubt one's capacity to love, and to feel that one's devotion is meaningless or, worse, malevolent” (p. 128). Later in the paper he writes:

By the traditional physician role, one feels wholly responsible for the course of the patient's illness, and believes it impermissible to experience any feelings toward the patient except kindly, attentive, long-suffering and helpful dedication … [which he subsequently interprets]. The therapist's functioning in the spirit of dedication represents an unconscious defense against his seeing clearly many crucial aspects of both his patient and himself—for example, sadism. (pp. 130-131)

I cannot tell whether I am opening with this quote from Searles as a way of framing this paper or as a way of providing myself with permission to present it.

Ms. A, a 34-year-old mother of one, was admitted to the Austen Riggs Center for intractable depression, with persistent suicidal ideation, acts of self-mutilation, and episodic alcohol abuse, set within the context of a severe character disorder. She was referred to the Center by her outpatient therapist of one year. The immediate circumstances surrounding her breakdown and entering the hospital included her husband's decision to seek a divorce after 10 years of marriage. Despite feeling dissatisfied in her marriage, Ms. A was hurt and deeply humiliated by her husband's decision. Manifestly her dissatisfaction with her marriage centered particularly on his refusal to tell her he loved her. This was not new. He had never told her this for idiosyncratic reasons relating to his own psychology. In addition to